Practice Tips: Documenting opioid management is as important as doing it

It's important to protect your practice by documenting opioid management in the medical record and adhering to extra regulatory requirements.

In the June ACP Internist, Practice Tips addressed how to develop office policies for opioid management. However, as with any clinical issue, “If it isn't documented, it didn't happen.” It is important to protect the practice by not only including documentation in the medical record but also adhering to extra regulatory requirements imposed on opioid prescribing.

ACP's Medical Home Builder addresses these issues and contains numerous resources designed to protect both the patient and the practice. The modules “Chronic Pain Management” and “Opioid Risk Management” can help a practice become consistent and confident in its treatment of patients taking long-term opioids.

When documenting opioid management, consider the following issues.

Prescriptions. If controlled substance prescriptions are provided, both federal and state laws must be followed. If the prescriptions are handwritten, ensure that they are legible. Write the patient's full name and date of birth. Write prescription strength and number of pills to be dispensed in both numbers and words. Do not sign uncompleted prescriptions.

Photocopy all handwritten and computer-printed controlled substance prescriptions before they are handed to the patient so that if the prescription is altered, the practice will have a copy of the original. Giving 28-day supplies rather than 30-day supplies of controlled substances prevents patients from running out of medications on the weekends. Information about e-prescribing, most of which is available without an ACP membership, may be found on the ACP website.

Universal precautions. These should be used when prescribing controlled substances to manage chronic pain. If the patient is on controlled substances for pain, an agreement/informed consent should be developed during the clinical visit to ensure that the patient and the practice know the stipulations and adhere to the agreement. In general, the agreement should be individualized, developed collaboratively, written in plain English (or the preferred language of the patient) and respectful of the patient's choices and concerns.

The agreement should include the intended benefits of using controlled substances, the risks of treatment, the specifics of your office policy and a care termination plan if a patient does not adhere to the treatment plan or exhibits aberrant medication-taking behavior. This includes selling prescription drugs; forging prescriptions; stealing or borrowing another patient's drugs; injecting oral formulations of drugs; obtaining prescription drugs from nonmedical sources; concurrently abusing related illicit drugs; initiating multiple unsanctioned dose escalations; losing prescriptions on a recurrent basis; aggressively complaining about need for higher doses; drug hoarding during periods of reduced symptoms; requesting specific drugs; acquiring similar drugs from other medical sources; and using a drug in an unapproved manner to treat another symptom.

Thoroughness. Make certain that all members of your team who interact with patients accurately and completely document their interactions. Make certain that you are in compliance with your state and federal laws. Components that should be documented include:

  • evaluation of the patient,
  • medical indication,
  • treatment plan,
  • pain contract/agreement and any subsequent conversations about the agreement,
  • objectives to determine treatment success,
  • informed consent and agreement for treatment,
  • periodic review of plan,
  • adherence monitoring and
  • consultation with specialist if/when appropriate.

Documentation of aberrant behavior is also critical. This should be done with a consistent tool such as the Pain Assessment and Documentation Tool (PADT™), available online, at each face-to-face visit, telephone encounter, request for prescription or any other type of encounter that seems aberrant.